Download Periodic Adult Health Maintenance Record

Periodic Adult Health Maintenance Record
For Women Aged 21 - 64
Created by: Dr. Stephen Milone and Dr. Stephanie Lopes Milone
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CURRENT PATIENT CONCERNS
CURRENT MEDICATIONS
REVIEW OF SYSTEMS
SOCIAL HISTORY
! Screen for gingivitis: Do your
gums bleed while brushing?
! Assess for medical impairment for
driving:
o Decreased Vision
o Decreased Hearing
o Decreased Flexibility
o Slow information processing
** consider driving assessment if +ve
! Assess for osteoporosis risk
factors †
! Screen for depression †
! Screen for Suicide risk (I) †
! Smoking:
pack-yrs
o Thinking of Quitting? Y / N
! Alcohol Intake: (Max: ♀-9, ♂-14)
______ drinks/week
o If > Max, do CAGE : /4
! Exercise: ________________
! Drug Use: Y / N
! Assess for STD if high risk †
! History of Domestic Violence? (I): Y
/N
! Current Employment:
o Assess for noise exposure
PAST MEDICAL HISTORY
! Cardiac Risk Factors
o Age: Post-menopausal
o Hypertension
o Hyperlipidemia
o Diabetes Mellitus
o Smoker
! Prior Rubella immunization?
! Prior exposure to chicken
pox: Y / N
! New immigrant from:_______
FAMILY HISTORY
Cardiac
Cancer
Psychiatric
Other
OTHER PAST MEDICAL HISTORY
! General R.O.S. Completed
ADDITIONAL COMMENTS
PHYSICAL EXAMINATION
Blood Pressure:
Height (m):
2
Weight (kg):
EVIDENCE-BASED
!
! Skin exam for moles:
!
o If high risk †
o General population (I)
!
! Oral cavity exam annually for smokers, ex-smokers,
and alcoholics
!
!
!
BMI (kg/m ):
Clinical Breast Exam (Ages 50-69)
Gonorrhea swab if high risk †
Chlamydia swab
o If high risk †
o General population
PAP test †
Pelvic exam for ovarian mass if at risk †
Examine for osteoporotic fractures †
AS INDICATED BY HISTORY
! General Physical Exam
Completed
ADDITIONAL COMMENTS
Grade A – Bold
Grade B – Italic
Grades C and I – Plain Text
References: Recommendations are from the Canadian Task Force (http://www.ctfphc.org) with the exception of the following recommendations which are from the United
States Preventative Health Task Force (http://www.ahrq.gov/clinic/uspstfix.htm): Aspirin for prophylaxis against cardiovascular events, screening for hypertension, physical activity
counseling, screening for obesity, as well as screening for cervical, prostate, and skin cancers. Last Updated April 2005.
COUNSELING ISSUES
! Smokers:
o Smoking cessation counseling
o Recommend eat green leafy
vegetables †
! Dental Advice:
o Brushing and flossing of teeth
o Annual professional scaling and
plaque removal
! Sun exposure counseling (I)
! Lifestyle Issues:
o Dietary counseling:
• If CV risk factors
• General population (I)
o Recommend regular physical activity (I) †
o Weight-bearing activity †
o Recommend weight reduction if BMI>30 (I)
o Advise against alcohol abuse if CAGE +ve †
o Education re: Gonorrhea prevention if at risk†
Dietician referral if at risk †
! Safety Issues:
o Drinking and driving
o Seatbelt use
o Bicycle helmet use
o Hearing protection if exposure to loud
machinery
INVESTIGATIONS AND TREATMENT
INVESTIGATIONS
! Screening for Colon Cancer:
o Fecal Occult Blood test q 1-2 years for
adults >50
o or Flexible Sigmoidoscopy q 1-2 years for
adults >50
! Colonoscopy if high risk†
! Mammogram q 1-2 years, Age 50-69
! DEXA scan q 1-2 years if 1 Major or 2 Minor
risk factors for osteoporosis †
! TB Skin test if high risk †
! HIV testing:
o If high risk †
o General population
! Glucose Fasting
o Age >40, q 3 years.
o if risk factors for Type-II Diabetes, q 1year†
! Screen for nutritional deficiency if at risk †
o Serum CBC, B12, Albumin, Iron
! Fasting lipid profile, Age >50 †
o If cardiac risk factors
o If no cardiac risk factors
TREATMENT
! Treatment of Hypertension:
o If Diastolic BP > 90
o If Systolic BP > 140
! Supplemental Vitamin D
o 800 IU/day, Age >50
! Folic Acid 0.4 mg/day for women capable of
becoming pregnant
! Dietary/Supplemental Calcium
o 1000 mg/d, Age 19-50
o 1500 mg/d, Age >50
! Treatment of hyperlipidemia †
! Aspirin to prevent cardiovascular events
o If high risk for coronary heart disease
o If asymptomatic, average CV risk
AS INDICATED BY HISTORY
AND PHYSICAL EXAM
SMOKERS
! Nicotine replacement therapy
! Referral smoking cessation program
IMMUNIZATIONS
! Pneumonia vaccination:
o If at risk †
o Age <55 and independent
! Varicella vaccination if no history of chicken
pox infection
! Influenza vaccination prior to each winter
flu season
! Rubella vaccination if capable of becoming
pregnant and no evidence of previous
immunization
SUMMARY OF PROPOSED TREATMENT, FOLLOW UP PLANS, OTHER COMMENTS
DATE
SIGNATURE
Grade A – Bold
Grade B – Italic
Grades C and I – Plain Text
References: Recommendations are from the Canadian Task Force (http://www.ctfphc.org) with the exception of the following recommendations which are from the United
States Preventative Health Task Force (http://www.ahrq.gov/clinic/uspstfix.htm): Aspirin for prophylaxis against cardiovascular events, screening for hypertension, physical activity
counseling, screening for obesity, as well as screening for cervical, prostate, and skin cancers. Last Updated April 2005.
ADULT HEALTH MAINTENANCE SELECTED GUIDELINES
REVIEW OF SYSTEMS AND SOCIAL HISTORY
Depression screen – all adults if there are integrated programs available (i.e. antidepressant medications and psychotherapeutic interventions) to
patients and access to case management or mental health care. (B)
Osteoporosis Risk Factors – See ‘Investigation” section below. (B)
STD High risk – Gay/bisexual men, prostitutes, IV drug users, other known STD infection, recent immigrant, blood transfusion between 1978-1985. (C)
Suicide High risk – High-risk groups include: those with a history of psychiatric illness, drug & alcohol abuse especially those living in isolation, those
with chronic terminal illness, Native Canadians especially young males, family history of suicide, first generation immigrant women. (I)
PHYSICAL EXAMINATION
Chlamydia swab, at risk – Age <25 and sexually active, new sexual partner within one year, >2 sexual partners within the past year, use of nonbarrier contraception, cervical friability, inter-menstrual bleeding, any vaginal discharge. (A) (C recommendation for low risk female)
Gonorrhea swab, high risk – Age < 30 with 2+ sexual partners, age < 16 at first sexual encounter, prostitutes, known STD contact. (A)
Osteoporotic Fractures – Examine for postural kyphosis, examine for back pain, and assess for vertical height loss. (C)
PAP Test – For all sexually active women annually until 3 consecutive normal results then can extend to every 3 years unless has had a total
hysterectomy or is >65 yrs. (A)
Pelvic examination, high risk – Known 1st degree relative with ovarian cancer. (C)
Skin Cancer High risk – 1st degree relative with malignant melanoma, fair-skinned, >50 moles, presence of atypical mole(s). (B)
COUNSELING ISSUES
Alcohol Abuse – Use 5-minute counseling session: 1 - Give feedback of CAGE results. 2 - Link excess alcohol use to negative consequences.
3 - Advise to decrease alcohol consumption. (B)
Dietician referral if high risk – Elderly, lives alone, alcoholic, diabetic. (B)
Gonorrhea Education – Abstinence prevents transmission, condom use decreases transmission. (B)
Physical activity – 30 min. moderate activity most days of the week (ex. Walking, Golfing-no cart, slow biking, raking leaves, household cleaning). (I)
Smokers and ex-smokers – Advise average of 7 daily servings of green leafy vegetables and/or fruit to decrease risk of lung cancer by two-fold. (B)
INVESTIGATIONS AND TREATMENT
Colonoscopy – Personal history of colonic polyps, family history of colon CA, Familial Adenomatous Polyposis, Hereditary Non-Polyposis Colorectal
Cancer (HNPCC). (B)
Diabetes Risk Factors – 1st degree relative with DM, high risk ethnicity (Native, Hispanic, Asian, South Asian, African), History of IGT, vascular
disease, History of GDM, History of macrosomic infant, hypertension, hyperlipidemia, overweight, abdominal obesity, polycystic ovarian syndrome,
acanthosis nigricans, schizophrenia.
HIV testing, at risk – Gay and bisexual men, prostitutes, IV drug use, recent immigrants from endemic areas, any STD infection. (A) (C
recommendation for general population)
Hyperlipidemia, screening – Guideline recommendation for fasting lipid profile every 5 years. Screening more frequently (every 1-2 years) if cardiac
risk factors present (not evidence-based). Base screening on clinical decision. (Consensus recommendation, no grading available at present)
Hyperlipidemia, treatment – Recommend repeating fasting lipid profile in 1-8 weeks. Base dietary and pharmacotherapy on target lipid values as
determined by level of risk. (B)
Nutritional deficiencies, screening – Alcoholic, elderly, institutionalized. (C)
Osteoporosis Risk Factors – Major: Age>65, fragility fracture <40 years old, vertebral compression fracture, propensity to fall, family history,
osteopenia on x-ray, systemic steroid use >3 months, malabsorption syndrome, primary hyperparathyroidism, menopause <45 years old,
hypogonadism. Minor: Weight <57 kg, chronic anticonvulsant use, smoker, rheumatoid arthritis, excessive EtOH, excessive caffeine, chronic
heparin use, weight loss >10% at age 25, low dietary calcium, hyperthyroidism. (B)
TB skin test – Immigrants from endemic areas, Native Canadian, close TB contact, IV drug use, alcohol abuse, chronic medical condition. (A)
Grade A – Bold
Grade B – Italic
Grades C and I – Plain Text
References: Recommendations are from the Canadian Task Force (http://www.ctfphc.org) with the exception of the following recommendations which are from the United
States Preventative Health Task Force (http://www.ahrq.gov/clinic/uspstfix.htm): Aspirin for prophylaxis against cardiovascular events, screening for hypertension, physical activity
counseling, screening for obesity, as well as screening for cervical, prostate, and skin cancers. Last Updated April 2005.